Table Of ContentRené K Marti, Ronald J van Heerwaarden
Osteotomies for
Posttraumatic Deformities
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René K Marti, Ronald J van Heerwaarden
Osteotomies for
Posttraumatic Deformities
1800 fi gures and illustrations
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Table of contents
Foreword (René K Marti) vi
Foreword (Christian van der Werken) viii
Introduction (Ronald J van Heerwaarden) x
Contributors xiii
1 Principles part 1
1.1 Posttraumatic deformities and osteotomies 3
1.2 General considerations on indications, types of osteotomy, bone healing, and methods of fi xation 17
1.3 Diagnostics and planning of deformity correction: formation of a surgical plan 33
2 Manual part 57
Clavicle Femur
2.1 Clavicle 66 2.9 Femur, proximal 318
2.10 Femur, shaft 330
Humerus
2.11 Femur, distal 370
2.2 Humerus, proximal 78 2.12 Knee joint 428
2.3 Humerus, distal 114
Tibia
2.4 Elbow joint 128
2.13 Tibia, proximal 478
Radius and ulna
2.14 Tibia, shaft 546
2.5 Radius and ulna, proximal and shaft 146 2.15 Tibia, distal 592
2.6 Radius and ulna, distal 184
Ankle and foot
Pelvis/hip joint
2.16 Ankle 616
2.7 Pelvic ring and acetabulum 228 2.17 Midfoot and hindfoot 650
2.8 Hip joint and femur, proximal 276
Appendix 701
Glossary 702 Abbreviations 704
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Foreword
The goal of this book is to present cases which should convince
the reader that secondary reconstruction of malunited
fractures still are an important part of modern orthopedics. Old
fashioned interventions performed with modern fi xation
techniques may lead to predictable long-term results.
In Amsterdam, for almost 30 years almost all osteotomies
have been documented and followed-up at regular intervals.
We do not wish to repeat published results of case series but
we want to present typical cases with long follow-up to
demonstrate the long-term results of the chosen or developed
René K Marti
operative techniques. These techniques are reproducible
Amsterdam, 2008
and may be easier to perform with modern implants as
demonstrated by the younger contributors to this book. We
may expect the same long term-result as long as the basic
Treatment of posttraumatic deformities provides a fi ne option principles are respected.
to prevent symptoms from malunions from developing into a
great handicap. A reconstructive surgical strategy aiming to The principles part is condensed to relevant theoretical
prevent further development of osteoarthritis and at the same information, details can be found in other textbooks.
time abolishing the pain by preservation of the natural joint is
rarely mentioned in the literature—the aim must be restoration In conclusion, the book mainly describes osteotomy techniques
of joint congruence and axial alignment. using standard implants and only to a lesser extent newly
developed specifi c implants. We hope that we can convince
But osteotomies in the treatment of degenerative and post- innovative young surgeons to consider joint preserving
traumatic arthritis seem to become a lost art. Even for young techniques in the treatment of posttraumatic deformities and
patients joint replacement is in vogue; the fact that joint arthritis.
preserving interventions may delay prosthetic replacement for
many years is no longer known to doctors and patients. A good example is Ronald J van Heerwaarden, one of my
former residents, who collaborated in editing this book after
In orthopedics only adequate documentation and long follow- organizing the international congress on osteotomies for
ups demonstrated the effi cacy of any intervention. posttraumatic deformities in Amsterdam in 2005. He has
quickly developed into an internationally recognized expert for
The treatment of posttraumatic problems has been one of the osteotomies around the knee. His contributions to the principles
major topics of the department of orthopedic surgery at the part of this book has led to a comprehensive description of the
University of Amsterdam. theoretical background important to the subject.
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Foreword—René K Marti
The chapter on formation of a surgical plan, coauthored by
Jeffrey W Mast and Cléber AJ Paccola, can be considered a
guide for the preparation of osteotomies in general.
The cases presented by Ronald J van Heerwaarden’s Limb
Deformity Reconstruction Unit are detailed descriptions of
new fi xation techniques for osteotomy.
It is impossible to thank all those who contributed to this book.
I would like to mention my secretary Evelien Goekoop and
Angelique Janssen (the secretary of Ronald J van Heerwaarden),
Roy Orie responsible for the long-term documentation, and of
course AO Publishing, especially in the person of Cristina Lusti
for the editing.
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Foreword
of secondary reconstruction. Today, however, patients are
more demanding, surgeons are becoming more and more
super-specialized, and, with the introduction of new diagnos-
tic modalities and the development of advanced surgical
techniques and modern implants, the situation has changed
dramatically. Nowadays, secondary reconstructions of post-
traumatic deformities are performed on broad indications
not only on patients suffering from complaints or medical
problems but also on those who are asymptomatic. The
decision to perform an osteotomy on a symptomatic—either
somatic, psychological, or cosmetic—patient is usually rather
Christian van der Werken
straightforward: the patient presents a problem and the
President of the AO Foundation
surgeon offers a solution. For a prophylactic osteotomy the
Utrecht, 2008
indication sometimes needs to be qualifi ed. By convincing an
asymptomatic—generally young—individual of the need for
reconstructive surgery in order to prevent secondary problems
In 1958, exactly 50 years ago, 13 visionary orthopedic in the future, the surgeon assumes great responsibility.
and trauma surgeons came together in Bienne, a small town
in the French-speaking part of Switzerland, where they When my predecessor as president of the AO Foundation,
founded a study group called the “Arbeitsgemeinschaft für René K Marti retired as Professor of Orthopedic Surgery in
Osteosynthese” (AO). The main reason for this initiative were 2005, a 2-day congress entitled “Osteotomies for Posttraumatic
the disappointing results of conservative and operative Deformities” was held in his honor in Amsterdam. The
fracture treatment at that time, resulting in permanent impressive invitation list included his orthopedic friends and
disability, especially after intraarticular and major long bone good colleagues, all renowned experts, from around the world.
fractures. AO developed new surgical techniques using Their presentations are the basis for this comprehensive
standard instruments and implants for internal fracture standard work of the same title.
fi xation, aiming at adequate reduction of the fracture
fragments and allowing functional postoperative treatment. This book covers the entire spectrum of corrective osteotomies
In this manner the two main underlying factors for of the extremities and the pelvis—on (un)usual indications,
poor clinical outcomes were addressed: reduction prevents with different—often virtuous—surgical techniques and with
malunion with posttraumatic deformity, while functional the—sometimes off-label—use of a variety of implants. In this
postoperative treatment is very effective against so-called era of artifi cial arthroplasties, the limits of joint preserving
“fracture disease” including muscle weakness and joint reconstructive surgery are being pushed, especially in patients
stiffness. with intraarticular and paraarticular deformities. Follow-ups of
several decades prove the effi cacy of most of these interventions
For centuries, posttraumatic deformities had been accepted by in the long run. The focus of this manual is on surgical skills
patients and doctors as an inevitable fate without any prospect and handicraft: preoperative planning, surgical approach,
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Foreword—Christian van der Werken
actual osteotomy, osteosynthesis, and rehabilitation. Not
specifi cally addressed—but easily perceptible between the
lines—are subjective factors like a good personal relationship
between patient and doctor based on mutual trust. These
factors are essential for proper patient selection and important
during the demanding rehabilitation process.
René K Marti and Ronald J van Heerwaarden are to be
congratulated on this standard work that will easily convince
creative orthopedic as well as trauma surgeons that joint-
preserving techniques should at least be considered in every
patient with posttraumatic deformities and osteoarthritis.
The authors have proven that there are almost no limits on
corrective osteotomies in posttraumatic deformities, thereby
leaving all options open for any type of additional surgical
intervention.
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